1. Acute Pancreatitis (1) C.L.I.P.S.
Etiology
Primarily: gallstones (40-70%), alcohol (25-35%), idiopathic (10-25%)
Medication (5%), hypertriglyceridemia (1-4%), cancer, infection, genes
5-10% of patients post ERCP develop pancreatitis
Diagnose if ≥ 2 of:
Abdominal pain c/w pancreatitis; serum amylase and/or lipase > 3x ULN; characteristic findings on abdominal imaging.
Lipase >> Amylase to test for suspected pancreatitis
Always get abdominal US for gallstones. CT or MRI if dx uncertain or failure to improve clinically in hours.
Consider triglycerides if no gallstones or history of EtOH.
Assessing and Addressing the Inflammatory Process is Key
Concern for local complications (e.g. necrosis, peripancreatic fluid collection) and organ failure (e.g. CV, respiratory, renal)
Severity per revised Atlanta classification system:
- Mild - no local complications or organ failure
- Moderately severe - local complications and/or transient organ failure
- Severe - persistent organ failure (>48 hours)
Most episodes will be mild, requiring only a brief admission, but you can’t differentiate with high accuracy initially.
CRP > 150 mg/L at 48h is common European marker for severe pancreatitis (sensitivity 80%, specificity 76%, PPV 67%, NPV 86%)
What is the best prognostic scoring system for predicting mortality with AP?
Insufficient evidence. BISAP can be done in the first 24 hours and no need for extra labs. (BISAP ≥3 has prognostic accuracy similar to APACHE II and Ranson’s).
Updated 1/2018 Stromberg

2. How large can the daily fluid deficits be with acute pancreatitis?
C.L.I.P.S.
Treatment
ICU for organ failure or BISAP ≥3
Aggressive hydration (e.g. lactated Ringers mL/hr) in all patients for first hours, unless CV or renal comorbid contraindication. Keep UOP ≥ 0.5 mL/kg/hour without renal failure.
Reassess fluid requirements frequently in first hours to achieve decrease in BUN.
Early enteral nutrition may shorten LOS - start oral immediately if mild/asymptomatic
Parenteral narcotics for pain, insuff. evidence for optimal selection
Other Complications
Infected necrosis, sepsis, abdominal compartment syndrome, splanchnic vein thrombosis, chronic pancreatitis
> 4 weeks – pancreatic pseudocyst, walled off necrosis – about 10% of these develop pseudoaneurysms
Within 5 years – new onset diabetes mellitus
Mortality
About 4% within 92 days of admission (about 2% within 14 days)
Prevention (based on etiology)
Cholecystectomy. Treat EtOH use disorders, triglycerides (> 1,000 mg/dL), ERCP procedure protocols/NSAIDS. Smoking cessation.
How large can the daily fluid deficits be with acute pancreatitis?
≥ 5 L/day may occur